Dosing Policies

NEW CLIENTS—First Month Orientation

Once you enter our program, you will be provided your first dose of methadone or buprenorphine by our staff.  The dose will be ordered by a physician or other qualified staff which is medically safe and in compliance with federal guidelines.  After your first dose, you are asked to remain in the clinic for half-an-hour to see that no serious adverse reactions occur.  You will be asked frequently in the first month of treatment about how your dose is affecting you. 

 

For those abusing standard opiates and who have been prescribed methadone, you will be able to request medication changes of up to 5mg per day until you reach 60mg per day total.  Once at 60mg/day you will be required to meet with a counselor who will submit a form for the physician to review and approve/deny medication changes.  Once your first 30 days in treatment has ended you will not be allowed to make request medication changes except via your counselor.

 

For those abusing fentanyl and who have been prescribed methadone, you will be able to request medication changes of up to 5mg per day until you reach 70mg per day total.  Once at 70mg/day you will be required to meet with a counselor who will submit a form for the physician to review and approve/deny medication changes.  Once your first 30 days in treatment has ended you will not be allowed to make request medication changes except via your counselor.

 

For those being prescribed buprenorphine, you will meet daily with the medical provider for evaluation and titration or your dose until stabilization is achieved.

 

You should know what to look for regarding overmedication and under-medication.  Signs you are overmedicated include feeling sleepy, sedated, or short-of-air.  These are serious signs of overmedication and you should notify the clinic as soon as possible.  Signs of under-medication include frequent opioid cravings, achiness, diarrhea, and restless sleep.  Typically the best indicator of appropriate dosing is your ability to sleep through the night.

 

TRANSFER CLIENTS

If you transfer from another methadone program, your dose level and attendance schedule will be transferred with you.  We are required to verify this information with the clinic you are leaving.  We will attempt to make the transition as seamless as possible.  You will be required to be seen by our physician prior to receiving medication as a client of our program.

 

TRAVEL DOSING

At your request, we will make appropriate dosing arrangements at a clinic near your destination.  Any request for travel mediation should be made at least a week in advance to allow for physician, state and federal approvals, if necessary.

 

DOSING RULES

Our clinic has specific time during which you may enter the facility for medication or prescription pickup.  These dosing hours are 5:30AM-9:30AM and 12Noon-1:30PM, Monday through Friday, 5:30AM-9:00AM Saturday.  The clinic is closed all Sundays and all state and federal holidays.  We will notify you of any holiday or special closing at least 30 days prior to the closing.  If you are late to the clinic, even by a few seconds, you will not be allowed into the facility.  If you have an ongoing problem with regular dosing hours because of travel or employment, special arrangements may be considered, please discuss the problem with your counselor.  Documentation of your circumstances and illicit-substance free drug screen(s) will be required for state and federal approval for additional take-home medication.

 

When you are at the dosing window, appropriate behavior is expected.  This includes not talking on cell phones or wearing sunglasses.  When taking a dose of medication observed by our staff, you must speak to the medicating nurse prior to leaving the dosing window, so that we are assured the dose has been ingested.  All cups used for medication may not leave the dosing window.  If you require a cup of water to be able to provide a urine drug screen, you need to speak with a counselor; we can provide you with a non-medicating cup.  Following consuming your dose at the medicating window, please do not wait or socialize at the dosing window.

 

CALL BACK POLICY

As a part of our diversion control plan (take home dose control plan), any client with take-home doses may be contacted and required to return to the clinic for a check of the take-home medication.  If you are contacted via phone call or voice mail at a number you have provided, you will have 24 hours to return to the clinic with your remaining take-home doses and any empty bottles. It is your responsibility as a client to insure that the phone number and contact information that is on hand is accurate. On the day you return, you will not ingest that day’s dose until after your medication has been inventoried by a staff nurse.  A drug screen may also be performed at this time to verify methadone and methadone metabolite or buprenorphine are present in your system.  If you fail to return within the 24 hour window, you will lose your take-home status (down phased to Phase 1) for 30 days, after 30 days you will be allowed to regain that level of take-home privileges through urine drug screens and attendance.

 

FIT FOR DOSING

All clients are required to be “fit for dosing”.  This includes but is not limited to zero signs/symptoms of intoxication from alcohol or other substances.  You may be asked to provide a drug screen based on clinical observation of intoxication.  Failure to provide drug screen samples upon request may jeopardize your enrollment in our program.  By federal law, we may medicate you at half your dose for signs of intoxication.  We reserve the right to refuse to medicate any client who appears to be under the influence of any substance (prescribed or illicit).

 

ALERT FLAGS

Our computer system has “alert flags” so that the medicating nurse may notify you which specific staff member needs to see you prior to or following dosing.  Please cooperate with clinic staff at all times during this process.  We will do our best to speak with you prior to reaching the medicating nurse and removing the alert.  Please do not speak rudely to the medicating nurse if the alert was not removed appropriately, they are not capable of removing the alert.  Another staff member will have to do this for the nurse.

 

DOSE CHANGES

After medication changes please allow 72 hours to completely feel the effects of the new level (increase or decrease).  Do not expect a dose change to be effective during the first day.  Methadone and buprenorphine blood level tend to be consistent for 24-36 hours, which is why it can be dosed only once per day.

 

When to increase:  Moderate to severe physical withdrawal experienced 4-16 hours after the observed dose.

When to remain:  Comfortable during the first 2-8 hours after dosing with mild withdrawal such as simple anxiety and insomnia for the remainder of the 24 hours.  You may experience even moderate withdrawal towards the end of the 24 hours (in this case more time in treatment, not more medication is indicated).

When to reduce dose:  Any sensation, no matter how mild, of being sedated, high or loaded during the first seven days after a medication increase.  Remember the dose response/effect will be more pronounced after the next dose, assuming a steady state has not been reached yet.

 

Vomiting your dose:  We may not be able to replace a vomited dose due to federal regulations.  At a minimum the vomitus must be observed by a staff member inside the building such that we can verify the appearance of methadone in it.  You may be asked to wait half-an-hour prior to being re-medicated to partially determine the possibility of methadone previously ingested being absorbed.  Doses vomited at home cannot be replaced. 

 

DRUG TESTING

Each client is required to submit a drug screen specimen when requested (urine or saliva based).  According to state standards, we will collect a minimum of one drug screen per month.  At our discretion you may be required to provide an observed urine based drug screen.  In such case, a same sex staff member will observe the collection of a urine drug screen specimen.  If you wish to provide an observed oral drug screen instead of a standard urine drug screen, you will be charged a fee for the oral drug screen. In addition, state regulations require additional weekly drug screens if the client test positive for illicit substances in their previous drug screen. Once the client provides one licit drug screen they will be removed from the required weekly drug screens and allowed to progress in phases as long as they continue to provide licit drug screens

 

NOTE:  Failure to provide a drug screen specimen upon request is considered a serious infraction of our rules which seriously jeopardizes your enrollment in our program.

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MISSED DOSES

Metro discourages missing any dose which you are scheduled to take.  It is our position that continued and consistent dosing is a necessary part of your treatment.  This is why when you have been absent; you may be required to be evaluated by a staff member prior to dosing.  A regular pattern of missed dosing may result in the loss of ALL take home privileges including Sunday.  After missing several consecutive days, your dose may be reduced as medically indicated in order to protect your health and well-being.  Any day that you miss your dose we request that you contact the clinic to notify us of the reason for missing (this is a courtesy).   After fourteen days of continuous, unexcused absences from dosing, you will have to be evaluated by a physician or other medical staff for continued participation in our program.  After twenty-one days of absences, you will be discharged from our program.

 

TAKE HOME MEDICATION

Take home medication is a PRIVILEGE that must be earned.  This is done by demonstrating to the program that you can safely handle the take home dose.  This is accomplished through providing drug screen free from illicit substances and positive progress in treatment.  The recommendation for additional take home doses originates with your primary counselor but must be approved by the physician.  The physician will determine your eligibility based upon federal criteria.  A requirement of getting take home medication is that you must have a lock box when you pick up the take home medication as well as your previous/empty take home bottles.

 

 

TAKE HOME BOTTLES

ALL empty bottles used for take home medication MUST be returned to the clinic with the proper label when you return to take more take home doses.  Client who fails to return take home bottles may have to attend the clinic more frequently until to missing bottle(s) is returned.  You may be denied addition take home medication until the bottle(s) is returned.  The label must be intact and legible on the bottle including your name and the appropriate date which it was given to you. Couples who attend the program must have their own bottles when returning to the clinic per DEA regulations.

 

LOST OR STOLEN DOSES

Methadone is a Schedule II narcotic, buprenorphine is a Schedule III narcotic, and thsy should be considered dangerous.  They can be fatal if consumed by a child or someone not tolerant to opioids.  Your take home medication is a privilege and should be considered a trust given to you in your treatment.  Methadone and buprenorphine, as well as all medicines should be stored under lock and key so unauthorized persons will not have access.

 

If your take home medication is lost or stolen, you should report it to the police.  Since methadone and buprenorphine are state and federally regulated narcotics and your bottle is labeled with your name, a lost bottle could result in a loss of confidentiality about your treatment or in harm to another person that you would be liable for.  Lost, stolen or spilled take home dose cannot be replaced by our program and could result in the loss of regular take home privileges.

 

 Regular take home medication will be permitted if:

1. Amount of time in treatment (see below)

2. Drug screen results which must show methadone, methadone metabolite and only approved prescription medications

3. Attendance is per your approved schedule

4. No serious behavior problems or known criminal activity

5. Medication is not suspected to be sold or transferred to another person especially not children

6. No illicit alcohol or other drug abuse

7. Stability in home environment and social relationships

8. Transfer records, if applicable, are on file and meet with all other requirements

9. Intake/admission process has been completed

10. All other rules of the program are followed including payment of account to no more than one week’s worth in the arrears.

 

Maximum number of methadone take home doses permitted by federal law is based upon time in treatment.  We are permitted to provide take home doses for days that the clinic is closed such as state holidays and Sunday.  Therefore, according to federal law the maximum number of take home doses is:

            Level               Number of take home doses                           Time in treatment needed

            Phase 1:           Sunday only per week                                                Available upon intake

            Phase 1A:         Sunday plus one (1) other day per week                       Minimum 14 days

            Phase 2:           Sunday plus two (2) other days per week                                 Minimum 3 months

            Phase 3:           Sunday plus three (3) other days per week                   Minimum 6 months

            Phase 4:           Sunday plus five (5) other days per week                    Minimum 9 months

            Phase 5:           Maximum thirteen (13) at a time                                  Minimum 12 months

            Phase 6:           Maximum twenty-seven (27) at a time                         Minimum 24 months

 

If you transfer from another clinic, you get to keep your time in treatment from your previous program.

 

Special take home doses or emergency doses may be approved by the physician, the state methadone authority and the Center for Substance Abuse Treatment (CSAT).  You must have a recent illicit substance free drug screen, and have completed 90 days in treatment, prior to being able to apply for special take home doses.  Reasons that would be considered for special take home doses would include but not limited to personal/family crisis, travel, employment or other exceptional circumstances.  Generally, a request for special take home doses will need to be made a week in advance. 

Individual dose reduction (IDR) or tapering

 

Medically Supervised Withdrawal

In accordance with the program’s goals and federal consent for treatment, the goal of opioid treatment is total rehabilitation of the client.  The eventual withdrawal from the use of ALL drugs is an appropriate treatment goal.  This includes methadone and buprenorphine.

 

Every client is evaluated for the feasibility of methadone or buprenorphine tapering at regular intervals as well as upon request.  The decision to begin methadone or buprenorphine tapering is a serious and important decision.  It will depend upon:

1. Your progress in counseling.

2. The absence of any non-prescribed drug use for a minimum of three (3) months prior to beginning the tapering.

3. You are gainfully employed or have stable income and stable relationships.

4. Additional items may be identified after completing the Tapering/Detoxification checklist.

We expect that a medically supervised tapering schedule will last at a minimum six (6) months to be most successful.

 

The client determines that they have successfully completed his/her treatment.  And client believes that he/she has reached his/her goals and objectives and is ready to begin a medically supervised tapering schedule from the methadone or buprenorphine.  The dose changes and the pace of the tapering are individually determined with the assistance of the medical director.  During medically supervised tapering, you (the client) retain the option of asking for a dose change within the boundaries of the schedule or to return to maintenance status at anytime.  It is imperative that you, your counselor and the physician take your journey of tapering together.

 

As a part of your ongoing success, we offer free counseling services up to one month for those clients who successfully complete a medically supervised tapering schedule or up to one month for those client who complete an administrative/against-medical-advice tapering schedule.  We recommend that as a part of this clients submit drug screens (at the cost of the client) to demonstrate to themselves that they have been successful.

 

Administrative/Against-medical-advice Tapering

 The client will not be provided an opportunity to return to maintenance or adjust the tapering schedule.  Once discharged for this type of tapering the client will have to wait a minimum of thirty (30) days before reapplying to the program.

 

Section Five—Drug interaction and abuse

 

PRESCRIPTION AND OTHER DRUGS

Methadone and buprenorphine can interact with other prescription and non-prescription medications and herbals.  Every prescription medication and over-the-counter medication or herbal should be discussed with medical staff and counseling staff.  This is for your safety.  Copies of all prescriptions must be supplied to the program every 60-days at a minimum. Clients will have 7 days after intake or annual physical exam to provide a copy of all current prescriptions they are receiving or they will be placed on a “stop dose” until they do so.  We also require a signed consent to contact the prescribing practitioner to consider your drug screens as “licit”.  If you refuse to comply with this request, you will be ineligible for additional take home doses. 

 

Combining methadone or buprenorphine and anti-tuberculosis or anti-seizure medications may cause some unpleasant side effects.  Let all physicians and pharmacists know if you are taking these substances at the same time.

 

Using certain types of medications may precipitate serious withdrawal symptoms when taking methadone or buprenorphine, some of these include naloxone (Narcan®), naltrexone (ReVia®), butorphanol (Stadol®), pentazocine (Talwin®), nalbuphine (Nubain®), or tramadol (Ultram®). Buprenorphine (Buprenex®) may cause withdrawal symptoms in those who are prescribed methadone.  Do not accept these medications while on methadone or buprenorphine except in the case of an overdose.

 

Methadone or buprenorphine in combination with any of the following may cause serious injury up to and including death:  other opioids, tranquilizers, sleeping pills and alcohol.  Our medical staff will be glad to discuss any prescription medications as they pertain to methadone.

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RELAPSE

Re-using after being drug free can be a temporary slip this is called relapse.  During treatment in our program, it is possible to learn skills and strategies to prevent temporary return to substance abuse.  For each client this experience will be unique.  Our counselors will work with you to prevent the spiral down that may start with relapse.  Your responsibility is to notify us honestly when you begin to think excessively about using illicit substances.

 

DRUG ABUSE

Methadone and buprenorphine are synthetic opioid analgesics with multiple actions and side effects similar to other opioid compounds (such as Dilaudid®, heroin, morphine, codeine, Darvon®, Demerol®, Percodan®, etc.), the most prominent of which involve the central nervous system (the brain and spinal cord) and the structures composed of smooth muscle (intestines).  Although the potencies and specific adverse side effects of various opioids differ, the overall effect upon the brain and its vital centers, such as breathing, is as a depressant.

 

Methadone or buprenorphine alone or combined with other opioids or benzodiazepines may cause SEVERE SEDATION, RESPIRATORY DEPRESSION, WHICH CAN LEAD TO RESPIRATORY ARREST, CIRCULATORY COLLAPSE AND CARDIAC ARREST.    If you experience ANY BREATHING DIFFICULTY or if others notice you are overly sedated such as abnormal snoring, you MUST visit an emergency room for evaluation immediately.  Contact emergency service personnel and explain the situation, this may be LIFE THREATENING!  The treatment is use of naloxone (Narcan®), this will induce withdrawal symptoms but it may save your life.

 

Methadone and buprenorphine are also long-acting narcotics. Methadone and buprenorphine should not be combined with any other long-acting central nervous system depressant such as diazepam or OxyContin®.  This type of combination may be fatal.

 

A positive drug screen for cocaine will lead us to assume cocaine was used.  Drugs such as Lidocaine®, Benzocaine®, and Procaine®, should not cause drug testing to show positive for cocaine.

 

An illicit drug screen result can potentially result in the loss of take home privileges and may result in six days per week attendance.  Continued illicit drug screens may indicate treatment failure and lead to administrative tapering or discharge from our program.  If you are unable to demonstrate a reduction in the harmful side effects of substance abuse within a reasonable time frame, you may be administratively discharged.  We will make every effort to assist you in preventing this outcome.

 

Drugs that are generally detectable by drug screen used in our program are listed below.  Many of these substances interact with methadone and may cause serious, possibly even fatal, reactions.

 

OPIOIDS

Bancap

Lortab

Hycotuss

Percocet

Tussionex

Codeine

Fiorinal w/ codeine

Methadone

Percodan

Tylenol w/ codeine

Darvon

Heroin

Novihistine DH

Propoxyphene

Tylox

Demerol

Hycodan

Nubain

Robitussin AC

Ultram

Dilaudid

Hycomine

Opium

Roxanol

Vicodin

Donnagel PG

Hydrocodone

Oxycodone

Stadol

Fentanyl

Hydrocet

OxyContin

Talwin

 

BARBITURATES

Amytal (amobarbital)

Dannatal

Nembutal

Seconal (secobarbital)

Butisol (butabarbital)

Fiorinal

Phenobarbital

 

BENZODIAZEPINES

Ativan

Dalmane

Serax

Valium

Klonopin

Halcion

Tranxene

Xanax

 

STIMULANTS

Adderall

Cocaine

Cylert

Exstacy (MDMA)

Ritalin

Amphetamine

Concerta

Desoxyn

Methamphetamine

 

 

WARNING:  Over the counter stimulants (white crosses, ephdra, ephedrine, etc.) may result in a positive drug screen for amphetamines and will be counted as illicit.  Certain herbals may test positive as benzodiazepines, these will also be counted as illicit.

 

If you believe that a drug screen is incorrectly reported, you have 30 days to request that confirmatory testing be completed.  Since this is your request, you may have to pay for the confirmatory testing prior to it being ordered.  If the original result is shown to have been incorrect, we will credit your account the cost of the confirmatory testing you had already paid.

Benzodiazepine Protocol

The maximum allowable daily dosage for methadone clients that provide illicit drug screens for benzodiazepines will be 80mg/day.

 

Those clients whose daily methadone medication dosage is greater than 80mg, and who test positive for an illicit benzodiazepine, will immediately have their medication level decreased to 80mg/day.

 

If the client wishes to challenge the results as a false positive by having it retested by the lab (GCMS/ETG test), the program will not reduce the client’s medication level until the re-test results have been received.  The client has 7 days from the date that they are notified of the illicit drug screen, to determine if they will have the specimen retested. 

 

Clients must provide three consecutive benzodiazepine free drug screens before they will be considered for a methadone medication increase above 80mg/day.

 

A physician must authorize any methadone medication increase above 80mg/day for those clients that have a prescription for benzodiazepines. The counselor must complete and submit a benzodiazepine checklist for the physician's review with the request for a medication increase.

 

Fentanyl Protocol

The maximum allowable daily dosage of methadone for clients that provide illicit drug screens for Fentanyl, and are illicit for any other substance, will be 80mg/day.

 

If the client wishes to challenge the results as a false positive by having it retested by the lab (LCMS test) it will cost $48.00 and is non refundable regardless of the outcome of the retest.

 

For each medication increase above 80mg of methadone the client must provide a Fentanyl free Observed Onsite drug screen. (The cost is $5.00 for the Fentanyl dip and $15.00 for the Onsite) If it is determined to be a licit screen, a COWS assessment can be conducted to determine if the client qualifies for a medication increase.

 

If the client has tested positive for Fentanyl at any point, they will be required to request a Fentanyl test with their drug screens in order to increase in phase. (This test is $5.00.)

 

If the client has provided a positive Fentanyl test and are above Phase 1, they will be required to purchase a Fentanyl dip with all future drug screens OR acknowledge use by signing the illicit use book. If the client refuses to comply with either option, it will result in an automatic decrease in Phase level.

 

                                               

Section Six—Clinic policies and Client expectations

 

PROBLEM RESOLUTION

The program director is the person responsible for the day to day operations of the clinic.  If you have a problem with any of the policies or procedures or any staff member of the program, you are encouraged to speak with the program director to resolve any misunderstanding or problem.  All conversations with the program director will be kept confidential up to the point where disclosure is necessary to conduct an investigation of allegations.  Problems concerning your treatment should first be addressed with your counselor, before being brought to the program director.